Sudden death of an alcoholic elderly man with acute esophageal necrosis (black esophagus)

We report a fatal case of acute esophageal necrosis (black esophagus) in an elderly male with alcohol abuse who was found dead with coffee-ground vomiting. A postmortem examination revealed severe anemia and marked black coloring of the esophagus from the upper to the bottom end. This was accompanied by histologic evidence of extensive mucosal necrosis. Alcohol abuse and esophagitis-related vomiting were both considered to be factors that led to the acute fatal esophageal necrosis. The cause of death was undetermined. We discuss the possible role of acute esophageal necrosis in the cause of sudden death.     

Copper-binding protein in acute copper poisoning

This paper presents a suicide case of copper sulfate ingestion. Post-mortem autopsy revealed mucous membrane necrosis of the esophagus and the stomach. Histological examination revealed centrilobular necrosis in the liver and renal insufficiency. The quantitative determination of copper, zinc and cadmium in various tissues showed that the copper concentrations in blood, liver, kidney and lung were 3.5-24-fold higher than those of the normal level, whereas zinc and cadmium concentrations were within normal range. Chromatographical patterns on Sephadex G-75 showed that most of the accumulated copper in the liver and kidney was bound to metallothionein (MT), a low molecular weight protein with high metal binding capacity which plays a role in the detoxification of heavy metals, while no copper bound to MT was found in the lung. These results suggest that the formation of Cu-induced MT in the liver and kidney occurred at the early stage in fatal acute copper poisoning.     

Demonstration of esophageal varices postmortem by gastroesophageal phlebography

The study presents a method for the demonstration of esophageal varices at autopsy by gastroesophageal phlebography. The veins visible on the radiographs were controlled and evaluated by studying the gross appearance of sections of the esophagus at the level of the varicose veins and by histologic examination of the sections. The phlebography was found to be useful in estimating the varicose and normal veins of the esophagus. The study indicates further that the degree of varicosity is not always proportional to the severity of cirrhosis of the liver, and there may be varicose esophageal veins in patients with liver or heart disorders without hepatic cirrhosis.     

Sudden Unexpected Death Due to Left Subclavian Artery‐esophageal Fistula Caused by Fish Bone

A 53‐year‐old woman was admitted to the hospital due to unexpected dizziness and died the following morning. To investigate the cause of death, a forensic autopsy along with histological examination was performed 3 days after her death. The major findings of the autopsy were that a fish bone had pierced the left subclavian artery after perforating the esophagus with 680 mL of blood in the stomach and bloody and tarry contents were present in the intestines, and the cause of death was confirmed to be subsequent hemorrhagic shock. Unfortunately, none of her family realized that she had eaten a fish 4 days before the tragedy until the fish bone was found. The present case is rare and instructive. The histopathological findings of left subclavian artery‐esophageal fistula induced by a fish bone can be used as a reference in forensic practice.     

Sudden Death by Spontaneous Epiglottic Hematoma Secondary to High Blood Levels of Warfarin

A 67‐year‐old man was found dead, at his home. On external examination, we found a voluminous purplish black ecchymosis of the anterior neck area. On internal examination, we found a voluminous epiglottis hematoma completely obstructing the upper airway. It was associated with other sites of intra‐abdominal hemorrhage. Toxicological studies revealed the presence of warfarin at a concentration of 8.4 mg/L in peripheral blood, which supposes an INR well above 4.5. To conclude, we supposed death was due to asphyxia secondary to a spontaneous epiglottic hematoma caused by a high blood concentration of warfarin. Hemorrhage in the epiglottis is very rare. To our knowledge, our patient is the only case of “sudden death” reported with spontaneous epiglottic hematoma due to high blood concentration of warfarin. In forensic practice, an anterior neck ecchymosis, without trauma, may suggest hemorrhage into soft airway tissues. Pathology findings make it possible to exclude exogenous trauma.     

Fatal venlafaxine overdose with acinar zone 3 liver cell necrosis

We present a case of fatal venlafaxine overdose in a 34-year-old male with a history of depression and previous suicide attempts. He presented unwell, and his condition deteriorated with the development of rhabdomyocytolysis and renal failure. Although treatment was provided, this was unsuccessful, and he died within a day of his admission. A postmortem examination was performed, and the findings included an acinar zone 3 pattern of liver cell necrosis and a very high level of serum venlafaxine in the deceased. No other elevated drug levels were detected. From this case, it is clear that venlafaxine overdose was the primary cause of a fatal acinar zone 3 pattern of liver cell necrosis. As far as we are aware, this is the first reported case of fatal acinar zone 3 liver necrosis caused by venlafaxine overdose alone.     

Arterial-esophageal fistulae in patients requiring nasogastric esophageal intubation

A rare and potentially fatal cause of hematemesis is fistula formation between the esophagus and the vascular system. A case report of a 39-year-old woman with congenital aortic arch anomalies hospitalized for treatment of head injuries demonstrates the potential for iatrogenic esophageal trauma to initiate fistula formation between the esophagus and an anomalous arterial system. A literature review revealed 6 other cases of vascular-esophageal fistulae caused by nasogastric esophageal intubation. It is concluded that aortic arch anomalies increase the risk of esophageal injury and subsequent fistula formation from nasogastric esophageal intubation. In addition, the clinical features and pathologic findings of vascular-esophageal fistulae are reviewed.     

“Bubbles”—A Spot Diagnosis

Abstract: Aspiration of blood is a phenomenon observed in violent and natural death scenarios. Bloodstain patterns evolving from expectoration of aspired blood may look suspicious of a violent genesis and thus mislead crime scene investigators. In the present case, a woman was found lying in a pool of blood on the kitchen floor. Furthermore, bloodstains covered her face, clothing, and surrounding furniture and walls. Bloodstain pattern analysis and medicolegal inspection of the suspected scene of crime were carried out and revealed dispersed stains with enclosed gas bubbles in the absence of signs of physical violence leading to the assessment of a natural manner of death. The bloodstains were attributed to expiration of blood because of an internal bleeding. Medicolegal autopsy confirmed the on‐site diagnosis as a fatal esophageal varix rupture was found.     

An Autopsy Case of Sudden Unexplained Death Caused by Malaria*

Abstract: Sudden unexplained deaths, especially those unwitnessed can lead to forensic issues and would necessitate the need for a meticulous and complete postmortem examination including ancillary investigations to discover the cause of death. We herein report a case of sudden unexplained death caused by malaria in an apparently healthy individual. This fatal case is presented to remind the forensic pathologist of the possibility of malaria as a cause of sudden unexplained death in malaria‐endemic regions. In the present case, histopathological examination demonstrated the presence of parasitized red blood cells with malarial pigment in the blood capillaries in the brain, myocardium, pericardium, lungs, kidneys, liver, and the spleen. Cerebral malaria with acute renal insufficiency or pulmonary edema with an acute respiratory distress syndrome might have been the cause of death.     

Fatal high cervical spinal cord injury in an automobile accident complicating os odontoideum

We report a case where spinal instability from incomplete fusion of the dens of C2 (os odontoideum) allowed anterior displacement of the skull and first cervical vertebra following right frontal impact against the A pillar in an automobile accident. Resultant crushing and laceration of the spinal cord occurred at the level of C1 and C2. Without either radiographic investigation or detailed examination of the spine, the fatal injury might have been overlooked and death attributed to acute alcoholic poisoning because the blood alcohol level was .613%.     

Radiographic demonstration of esophageal and tracheal fistulas at autopsy using a contrasting medium that vulcanizes at room temperature

Esophageal and tracheal fistulas, which occur in 0.05% of medicolegal autopsies, were demonstrated in three cases by a postmortem radiographic technique using silicone rubber/lead oxide as a contrasting medium that vulcanizes at room temperature. In one 83-year-old male, a tracheoesophageal fistula was detected, which had developed after surgical repair of an esophageal rupture caused by a flexible fiberoptic endoscope. In a second case, carcinoma of the esophagus in a 78-year-old male had eroded the trachea and arcus of the aorta creating a fatal tracheoesophagoaortic fistula. In a third case, 55-year-old female developed a tracheobrachicephalic artery fistula as a result of an infiltrating cystic adenocarcinoma of the trachea, resulting in a fatal hemorrhage into the trachea. The results of this study indicate that diagnostic radiologic methods using a vulcanized contrasting medium are useful in supplementing normal dissection in autopsy cases with suspected fistulas of the esophagus or trachea.     

Fatal hepatic failure following accidental tramadol overdose

A case of fatal overdose of tramadol is described, occurring in a 67-year-old man with painful rib fractures who accidentally ingested more than the recommended daily dose. The mode of death was acute liver failure due to fulminant hepatic necrosis. Post-mortem toxicology was negative apart from revealing a blood tramadol concentration well above the normal therapeutic range. This is the first report of fatal tramadol ingestion occurring in a therapeutic setting and also the first tramadol-related death where the mechanism was liver failure.     

Fatal colchicine poisoning by accidental ingestion of meadow saffron-case report

A 62-year-old male died of colchicine poisoning after accidental ingestion of Colchicum autumnale (meadow saffron). He ate a salad of plant with green leaves regarded as wild garlic (Allium ursinum). A few hours later he developed symptoms of gastroenteritis and was admitted to hospital. In spite of gastric lavage, activated charcoal and supportive measures, multi-organ system failure developed over the next two days. Laboratory analysis showed highly elevated blood concentrations of hepatic enzymes, creatine kinase, lactate dehydrogenase and blood urea nitrogen, as well as leukocytopenia and thrombocytopenia. Mechanical ventilation, dopamine, noradrenaline, crystalloid solutions and fresh frozen plasma were applied but despite treatment the patient died five days after the ingestion. Post-mortem examination revealed hepatic centrilobular necrosis, nephrotoxic acute tubular necrosis, petechial bleeding in fatty tissue, blunt and shortened intestinal villi and cerebral toxic edema. Botanical identification of incriminated plant gave Colchicum autumnale which confirmed colchicine poisoning. Although the accidental ingestion of Colchicum autumnale is rare and to our knowledge only five such cases have been described in detail, this is the second fatal case in Croatia described in the last 3 years.     

Fatal Myocarditis Following Treatment with the PD‐1 Inhibitor Nivolumab

Therapeutic antibodies targeting the programmed cell death protein 1 (PD‐1) pathway function as immune checkpoint inhibitors, allowing the immune system to recognize tumors which otherwise escape immune surveillance. However, these agents can also elicit an autoimmune response by inhibiting the ability of non‐neoplastic tissues and regulatory cells to suppress the immune system. Here we present a fatal case of active myocarditis in a 55‐year‐old man with non‐small‐cell lung cancer which occurred following monotherapy with the PD‐1 inhibitor nivolumab (Opdivo). He presented with acute right‐sided heart failure and died 1 day after admission. Postmortem examination revealed multiple gelatinous lesions in the myocardium of the interventricular septum and the bilateral atria and ventricles which had microscopic features diagnostic of myocarditis. Subsequent studies failed to identify an infectious cause. Immune checkpoint inhibitors are an increasingly common addition to anticancer regimens and they should be considered in the evaluation of acute myocarditis.     

Toxicological findings in a multi-drug death involving propoxyphene, caffeine, phenacetin, acetaminophen and salicylate

The toxicological findings of a multi-drug related fatal poisoning are described here. A 35-year-old Caucasian male found dead on the kitchen floor was a known user of abused drugs and had been taking aspirin alone or in combination with phenacetin and caffeine for the relief of joint pains. The gross examination of the organs at autopsy revealed slight grooving of the uncus and various stages of necrosis in the renal papillae. Histological examination confirmed the gross appearance of pulmonary congestion and edema, cerebral edema and interstitial nephritis of the tubules. Toxicological evaluation of the blood and urine samples disclosed the presence of propoxyphene (51 and 250 mg/l), salicylate (185 and 2750 mg/l), caffeine (16 and 37 mg/l), and phenacetin (9.6 and 20 mg/l). Furthermore, acetaminophen also was present in the plasma (54 mg/l) and urine. A gas liquid chromatographic method for simultaneous analysis of phenacetin and caffeine utilizing a nitrogen phosphorus detector was proposed.     

Rupture of ascending aorta secondary to esophageal perforation by fish bone

Perforations of both esophagus and aorta after swallowing foreign bodies have been described, with aorto-esophageal fistulas at the level of the descending aorta or aortic arch. We present the case of a 48-year-old man with esophageal perforation by fish bone, mediastinitis, and evidence of perforation of the ascending aorta during surgical drainage of the mediastinum. At autopsy, a fish bone was found under the aortic arch. Serial histological macrosections of the mediastinic block allowed reconstruction of the type of injury suffered and a thorough analysis of mediastinic structures, with preservation of topographic relationships. Direct demonstration of the perforation of the posterior wall of ascending aorta was provided. Histological examination ascribed aortic perforation to migration of the fish bone and direct injury. This is the first anatomical and pathological study of an autopsy case of perforation of the ascending aorta by fish bone.     

Fatal Intoxication with Acetyl Fentanyl

Among the new psychoactive substances encountered in forensic investigations is the opioid, acetyl fentanyl. The death of a 28‐year‐old man from recreational use of this compound is reported. The decedent was found in the bathroom of his residence with a tourniquet secured around his arm and a syringe nearby. Postmortem examination findings included marked pulmonary and cerebral edema and needle track marks. Toxicological analysis revealed acetyl fentanyl in subclavian blood, liver, vitreous fluid, and urine at concentrations of 235 ng/mL, 2400 ng/g, 131 ng/mL, and 234 ng/mL, respectively. Acetyl fentanyl was also detected in the accompanying syringe. Death was attributed to recreational acetyl fentanyl abuse, likely through intravenous administration. The blood acetyl fentanyl concentration is considerably higher than typically found in fatal fentanyl intoxications. Analysis of this case underscores the need for consideration of a wide range of compounds with potential opioid‐agonist activity when investigating apparent recreational drug‐related deaths.     

Megaesophagus and Possible Mechanisms of Sudden Death

Abstract:  Achalasia is a neurodegenerative condition characterized by esophageal dysmotility and megaesophagus. Two cases are reported that demonstrate unexpected deaths associated with previously unsuspected achalasia. Case 1: A 66-year-old woman was found dead at her home. At autopsy significant stenosing coronary artery atherosclerosis was found with cardiac failure. In addition, a striking finding was narrowing of the distal esophagus with marked proximal dilatation. The esophagus was completely filled with a large amount of soft masticated food and was bulging anteriorly, compressing the left atrium. Death was attributed to ischemic heart disease complicated by previously unsuspected achalasia. Case 2: An 84-year-old man collapsed and suffered a respiratory arrest while eating. Internal examination revealed narrowing of the cardioesophageal junction with marked proximal dilatation of the esophagus that contained approximately 50 mL of soft semi-fluid masticated yellow food paste. Fragments of yellow masticated food remnants were present in upper and lower airways but not within the stomach. There was a history of dementia with symmetrical cerebral ventricular dilatation found at autopsy. Death was attributed to food asphyxia complicating previously unsuspected achalasia with dementia. Megaesophagus may, therefore, be a significant finding at autopsy that may either be a primary cause of unexpected death or else may exacerbate or compound the effects of pre-existing underlying disease.